Executive Summary

HL7 FHIR on Azure – A Global Approach to Healthcare Interoperability

Healthcare Interoperability has been a fleeting objective in the US and around the world. Efforts such as the creation of
the US Office of the National Coordinator for Health Information Technology (ONC) in 2004, which targeted a nationally
coordinated Health Information Technology (HIT) solution, have not reached the anticipated and hyped levels of success.

In a targeted effort to address Healthcare Interoperability, in 2011, the HL7 international organization looked at health data
exchange with a fresh pair of eyes leveraging modern approaches and technology such as RESTful based APIs and JSON.
general-purpose interface
The organization’s HL7 FHIR (Fast Health Interoperability Resources) Standard for Trial Use R2 (STU) became available in
2015, and the first normative edition “FHIR R4” is planned for October 2018.
and pull data between

HIMSS defines Healthcare interoperability as the ability of different information technology systems and software
applications to communicate, exchange data, and use the information that has been exchanged across organizational
boundaries in order to advance the effective delivery of healthcare. HIMSS also adds that data exchange schema and
standards permit data to be shared across clinician, lab, hospital, pharmacy, and patient regardless of the application or
application vendor. At Microsoft we believe that healthcare interoperability should also include areas such as Identity
Interoperability across the extended enterprise to enable clinical collaboration; data Interoperability to truly drive
insights, trigger actions, and accelerate outcomes; process Interoperability to extend and automate healthcare workflows;
device interoperability; and modern technology such as cloud computing and Blockchain to enable and accelerate
interoperability. We’ll explore some of these topics but for now, the focus is on HL7 FHIR, why it works, what
improvements it brings to healthcare interoperability over existing standards, and what Azure services support FHIR
development and implementation.

In this e-book “HL7 FHIR on Azure” we introduce and explore the ability to leverage the Microsoft Azure platform and
services to instantiate HL7 FHIR based servers, services, solutions and scenarios. As a cloud computing platform,
Microsoft Azure aligns well with the promise of the FHIR standard to be faster to learn, implement, and maintain at lower
cost; to be scalable and flexible; and to be a free standard. The e-book is multi-functional as it introduces FHIR
frameworks for payers, providers, patients, devices, interoperability, hybrid, and AI along with sample use cases and
workflows. The e-book is intended for those who are new to HL7 FHIR and for experienced developers.

More information on HL7 FHIR itself can be found here http://hl7.org/implement/standards/fhir/index.html.

 WHY FHIR?
Fast Healthcare Interoperability Resources (FHIR) is suitable for use in a variety of
contexts, such as mobile phone apps, cloud communications, Electronic Health Records
(EHR) data sharing, and server communication in large institutional healthcare providers.

REST DOCUMENTS
The RESTful API is a The document framework
general-purpose interface is provided to help with
that can be used to push computer-assisted human
and pull data between to human communication
systems. uses - which are not
uncommon in healthcare.

MESSAGES SERVICES
The messaging exchange FHIR is useful in a services
framework supports routing and setting where core
transfer of content betweeen functionality is exposed via
systems.. secure API frameworks.
FHIR offers many improvements over existing HL7 Standards

Strong foundation Human-readable

in Web standards: serialization
JSON, HTTPS, format for ease of
XML. OAuth, etc. use by developers

Multiple
implementation
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development

Evolutionary Support for RESTful

development path architectures,
from HL7 v2.x and seamless exchange
CDA: of information using
standards can messages or
co-exist and documents, and
leverage each other service based
architectures

Interoperability
out-of-the-box:
Concise and easily base resources
understood can be used as is,
specifications but can also be
adapted for local
requirements

FHIR combines the best features of HL7's v. 2.x , HL7 v. 3.0 and CDA
product lines while leveraging the latest web standards and
applying a tight focus on implementability. The use of FHIR
introduces the ability to integrate modern technology constructs.
 HL7 FHIR ON AZURE

AZURE SERVICES FOR FHIR

 Security, Compliance, and Privacy
Personal health information is protected in Microsoft business cloud services
Microsoft complies with all applicable regulatory requirements

HITRUST ISO/IEC 27001:2013 HITEC H

Health Information Trust ISO/IEC 27001 is a security standard that formally The HITECH Breach Notification Final Rule,
Alliance (HITRUST) Common specifies an Information Security Management System which requires giving notice to individuals
(ISMS) that is intended to bring information security and the government when a breach of
Security Framework (CSF) under explicit management control unsecured PHI occurs

SECURITY COMPLIANCE PRIVACY

MARS-E ISO/IEC 27018 HIPAA

The MARS-E 2.0 framework provides Information Security The Microsoft HIPAA BAA
information aimed at securing Management Standards covers more services that
protected data. any other cloud provider

Visit the Microsoft Trust Center for the full listing

 Azure Enterprise Integration Services

Logic Apps Service Bus Integration Account Function Apps

Handle the Contains Queue and Handles conversion Processes Azure
processing Topic Services of all Provider and service events
(transformation,
validation etc.) of Payer message types
FHIR resources in to FHIR resources
a workflow
manner

On-premise Data Gateway API Apps API Management Data Catalog

Provides for access Provides REST FHIR Provides a gateway Enables users to discover
to Database and File Services for discovering Public the data sources they need,
Shares in LAN API applications. and to understand the
Manages Internal data sources they find
and external API
 Azure Analytics Services
Azure Analytic Services are the foundation for event driven predictive decision support systems

Machine Learning Event Hubs Notification Hubs Time Series Insights

Creation, testing, Collects, transforms, Push notification engine Fully managed analytics,
operation, and and stores millions of for quickly sending storage, and
management of events millions of notifications visualization service
predictive analytic

These are the recommended Azure Data and Storage Services for HL7 FHIR
 Azure Device Services
Azure Device Services are the secure end point for Healthcare data

IoT Hub Event Hub Logic Apps Event Managment

Holds messages Collects, transforms, Handles the processing Provides managment
for processing and stores millions of of device data within a for medical devices
events from devices workflow manner

These are the recommended Azure Device Services for HL7 FHIR
 Azure Data and Storage Services
Azure Data Storage Services are the modern data stores which scale to fit FHIR needs.

Queue Storage Cosmos DB Data Lake Store Blob Storage

Hold messages for Repository for FHIR Archive for FHIR Repository for
processing resources Management resources attachments
of FHIR resources

These are the recommended Azure Data and Storage Services for HL7 FHIR
 Azure Security Services
Azure Security Services are a modern approach to integrating devices, EHR's, people and cloud services to form
a secure connection across data points

Key Vault Multi-Factor Authentication Oauth2 Active Directory

Stores cryptographic Multi-Factor Used for service to Secure access to
keys and other secrets Authentication helps service authentication on-premises and cloud
used by cloud apps and safeguard access to applications
services data and applications,

These are the recommended Azure Security Services for HL7 FHIR
Payer FRAMEWORK
Claims, Eligibility, Claims
Attachments, Payment
Reconciliation, Explanation
of Benefits

Financial

Exchange of

HIR
Provide inquiry and
Clinical exchange of care

Care
Documents that plans that enhance
conform to on F the coordination
in-progress between

Plan
profiles value-based care
DA

Pa
stakeholders
C-C

Re Clin ts
as ica en
on l
in chm
g
A tta
A system that Electronic
provides attachments are a
measure high priority for
evaluation results processing claims
and other
payer/provider
interactions
 Financial Use Case
Payer Framework

The Financial use case illustrates the communication flow between a payer and a
provider. Support the receiving and processing of the Eligibility resource and creation
of the EligibilityResponse resource. Enable the creation and submission of the
ProcessRequest resource and the receiving or obtaining of a ProcessResponse. This
will be used to request a ExplanationOfBenefit. Support the receiving and processing of
the ProcessRequest resource and creation of the ExplanationOfBenefit resource.
 C-CDA on FHIR Use Case
Payer Framework

The provider creates a C-CDA on FHIR document (Bundle containing a Composition and
supporting resources) and submits that document to the Payer.
The Payer validates the document against the C-CDA on FHIR profiles, saves it to the
FHIR Server, extracts discrete resources from the document, and displays it in a browser
using a style sheet.
 Care Plan Use Case
Patient Framework

This care plan illustrates the communication flow and documentation of a care plan
between a patient, a patient’s primary care provider or other care team members.
Authentication for the Patient uses OAuth2 and OpenID based upon the Smart of FHIR
Authorization Framework
Provider FRAMEWORK
Retrieval of Patient
diagnostic data

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A key challenge of
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the resources available in
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 Workflow Use Case
Provider Framework

A workflow is an essential part of healthcare. Admissions, transfers, discharges, orders and referrals
are the drivers of most activity within in-patient settings and a great deal of activity in community care as well.
FHIR is concerned with workflow when there's a need to share information about workflow state or relationships,
when there's a need to coordinate or drive the execution of workflow across systems and
when there's a need to define allowed actions, dependencies and conditions on behavior.
 Genomics Use Case
Provider Framework

Genomic data is of increasing importance to clinical care and secondary analysis.

FHIR Genomics consists of the Sequence resource and several profiles built on top of
existing FHIR resources (DiagnosticReport-genetics profile, DiagnosticOrder-genetics
profile, Observation-genetics profile). The Sequence resource is a core resource in FHIR
Genomics. It is used to represent complex genetGenomkicsics data. FHIR Genomics
focuses on clinical genetics data reporting
 Data Analytics Use Case
Provider Framework

Data Analytics can be used to access clinical data to support informatics research activities.
Common scenarios are Asthma Eligibility and Dyslipidemia Eligibility.
Azure Machine Learning and HD Insights are used to generate the report.
 HIE Use Case
Provider | Payer | Patient Frameworks

A Electronic health information exchange (HIE) allows doctors, nurses, pharmacists, other
health care providers and patients to appropriately access and securely share a patient's
vital medical information electronically-improving the speed, quality, safety and cost of
patient care. Provides patients with access to their health information, allowing them to
their health care online in a similar fashion to how they might manage finances
through on-line banking.
 Care Plan Use Case
Patient Framework

This care plan illustrates the communication flow and documentation of a care plan
between a patient, a patient’s primary care provider or other care team members.
Authentication for the Patient uses OAuth2 and OpenID based upon the Smart of FHIR
Authorization Framework
Device FRAMEWORK
Retrieve and display
information acquired from
devices

EHR

D
De age

Sy DS
Ma

m
ste
vic r

C
n
e

Manages data Medical Device

recording Event Processing
Services
Device Data Integration Use Case
Device Framework

Data collected from home and hospital medical devices is processed and stored in the
FHIR Repository as Device Component and Device Metric Resources. Typical scenarios
include Vital Signs Monitoring, Medication Administration, and Implanted Monitoring.
Interoperability
FRAMEWORK
Di

d
Retrieve and display
information acquired from
devices

EHR

device

De age

Sy DS
Ma

m
ste
vic r

C
n
e
Manages the
recording of data Medical Device
from the Medical Event Processing

framework
Device Services

Pr

P
Retrieval of Patient
diagnostic data

essential part of
Data Access
healthcare - CRUD Operations
admissions, transfers, on Patient
discharges, orders Resources
and referrals are the Pa
drivers of most
tie
activity
nt

Pr

Data Analytics
Reasoning
Clinical
Real-time clinical Access clinical data to
decision support support informatics
services research activities and

provider
allow participants to
evaluate how FHIR can
support research

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framework

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With CDS Hooks, EHRs

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It is used to can further integrate

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represent complex
genetics data. FHIR
Directories and FHIR and SMART into
Genomics focuses Scheduling with
on clinical genetics clinical decision
data reporting support
A key challenge of
healthcare is knowing about
the resources available in
the local, regional, and
global healthcare networks

Claims, Eligibility , Claims

Attachments, Payment
Reconciliation, Explanation

Financial

Exchange of

FHIR
Provide inquiry and
Clinical exchange of care

Care
Documents that plans that enhance
conform to the the coordination

A on
between

Pl
in-progress value-based care

an
stakeholders

C-CD
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payer
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A system that Electronic
provides attachments are a

Pt

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measure high priority for
evaluation results processing claims
and other
payer/provider
interactions

Follow the patient through

high-need episodes (e.g.,
acute illness), as well as
periods of health improve-
ment and maintenance

Care Plan

Pt
patient
Sc
he

framework
HI
du

Scheduling of
l in

Appointments Healthcare
Information
g

Exchanges
Hybrid FRAMEWORK

BizTalk Server
 COSMOS DB SERVER
Azure Cosmos DB provides turnkey global distribution, elastic scaling of throughput and storage worldwide, single-digit
millisecond latencies at the 99th percentile, five well-defined consistency levels, and guaranteed high availability, all backed
by industry-leading SLAs.

DATA
STORAGE
It is multi-model and supports
document, key-value, graph,
DOCUMENT and columnar data models.

REPOSITORY
Azure Cosmos DB
automatically indexes
data without requiring you
to deal with schema and
index management.

MONGO
SECURITY COMPATIBILTY
Encryption at rest is a phrase that refers the to You can use your existing MongoDB
encryption of data on non-volatile storage expertise, application code, and
devices such as Solid State Drives (SSDs) and tooling. You can develop applications
Hard Disks (HDDs). Azure Cosmos DB stores its
primary databases on SSD and its media using MongoDB and deploy them to
attachments and backups into Azure Blobs production using the fully managed,-
which are generally HDD-backed. With the globally distributed Cosmos DB
release of encryption at rest for Azure Cosmos service.
DB, all of your databases, media attachments,
and backups are now encrypted. This means
your data is now encrypted in transit (over the
network) and at rest (non-volatile storage),
providing you end-to-end encryption.
 Azure FHIR Server

The FHIR Server has three layers.

API: Uses Azure API Managment to handle all FHIR REST operations
Repository: Cosmos DB; Stores FHIR Resources, Operations Managment
Archive: Archival storage of FHIR Resources
 Bot Services Use Case
AI Framework

Uses the Azure Bot Service to collect answers to questions (FHIR Questionnaire resource) from
a patient or a provider. The Bot Service uses Azure Cognitive Speech Services.
Azure Machine Learning is used to evaluate the answers and save the resource to the FHIR Repository.
A Logic App handles the workflow.
Mapping TO FHIR
PROFILES

Pa

Pr

HL7 FHIR supports

P t JSON and XML document formats.

D Use Azure Services to convert HL7 v2.x and 3.0

to HL7 FHIR Resources.

CONVERTING
HL7 v. 2. AND v. 3.0
X
 Mapping HL7 v. 2.x and 3.0
to FHIR PROFILES

Call a Function App from a Logic App, to convert HL7 v. 2.x Flat Files to XML.
By leveraging Logic Apps with the Integration Account Service, you can map HL7 v.2.x and 3.0
XML documents to FHIR Resources in XML Format Once mapped, they can be converted
to JSON Format for storing in the FHIR Server..
SUMMARY
In this eBook, you have learned about

1
• Introduction to HL7 FHIR

2 AZURE FRAMEWORKS
• Patient, Payer, Provider, Device, Artificial Intelligence (AI)
• Use Cases
• Security
3 FHIR SERVER ON AZURE
• Leverage Azure Cosmos DB to create a compliant FHIR Server

4 INTEROPERABILITY
• The Interoperability Framework enables different information technology
systems and software applications to communicate

5 • Converting HL7 v. 2.x and 3.0 to FHIR Resources

6 HYBRID INTERGRATION
• Use the On-premise Data Gateway to connect BizTalk,
databases, and files to Azure

AZURE TRUST PORTAL

7 • Visit the Azure Trust Portal
 The following page is Next Steps

The page contains links to:

• Contacts
• Resources
• Sources
• Sample and SDK
• Case Studies

The content in this page will be periodically updated.

It is recommended that you bookmark the web page
 Next Steps

SOURCES CONTACTS

RESOURCES

SAMPLES
and
SDK

CASE AUTHOR
STUDIES PROFILE

If you have any questions about the contents of this eBook, please contact the HL7 FHIR Microsoft Working Group